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<div id="printheader"><h1 class="p_Heading1"><span class="f_Heading1">Data Dictionary</span></h1>
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<p>The data dictionary enumerates all of the indicators collected in the IQCare-PADMT form set. The display label, display type, select list options, business rules and if the field is a required or data quality check field is documented in the data dictionary. </p>
<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A1_ICON" class="dropdown-toggle-icon" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A1','TOGGLE0186A1_ICON')">Registration</a></td></tr></table></div><div id="TOGGLE0186A1" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none; border-spacing:0px; border-collapse:collapse;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 16pt; font-weight: bold;">Registration Form</span></p>
</td>
<td style="vertical-align:top; width:150px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;">Last updated: June 2014</p>
</td>
<td style="vertical-align:top; width:150px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:39px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Labelled</span></p>
</td>
<td style="vertical-align:top; width:150px; height:39px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Display Type</span></p>
</td>
<td style="vertical-align:top; width:150px; height:39px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Options/list/units</span></p>
</td>
<td style="vertical-align:top; width:158px; height:39px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Business Rule</span></p>
</td>
<td style="vertical-align:top; width:117px; height:39px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Required Field</span></p>
</td>
<td style="vertical-align:top; width:149px; height:39px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Data Quality Check</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Tab: Patient Information</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Last Name</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">First Name</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:66px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">DOB</p>
</td>
<td style="vertical-align:top; width:150px; height:66px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:150px; height:66px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:66px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Reverse calculation - ok to have June 15 and estimated radio checked</p>
</td>
<td style="vertical-align:top; width:117px; height:66px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
<td style="vertical-align:top; width:149px; height:66px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Age - Months</p>
<p style="margin: 0px 0px 0px 0px;">Age - Years</p>
</td>
<td style="vertical-align:top; width:150px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Calculated</p>
</td>
<td style="vertical-align:top; width:117px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Sex</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Registration Date</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Patient Physical Address</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Street - house number</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Suburb / Village / Farm</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox </p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Sub district</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">District</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Telephone contact</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Address comments</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Patient Postal Address</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Postal Address</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multiline TextBox</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Postal Code</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Patient Source</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:132px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Entry Point</p>
</td>
<td style="vertical-align:top; width:150px; height:132px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td colspan="4" style="vertical-align:top; width:150px; height:132px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">PMTCT</p>
<p style="margin: 0px 0px 0px 0px;">VCT</p>
<p style="margin: 0px 0px 0px 0px;">TB Clinic</p>
<p style="margin: 0px 0px 0px 0px;">OPD</p>
<p style="margin: 0px 0px 0px 0px;">IPD-Paediatric</p>
<p style="margin: 0px 0px 0px 0px;">MCH-child</p>
<p style="margin: 0px 0px 0px 0px;">Other, Closure of clinic</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Other (Specify e.g (STI)</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Entry point - Other</p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Tab: Caregiver Information</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Caregiver Contact</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Caregiver Name</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Caregiver DOB</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Caregiver Age</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Calculated</p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Caregiver Gender</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:148px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Caregiver Relationship</p>
</td>
<td style="vertical-align:top; width:150px; height:148px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td colspan="4" style="vertical-align:top; width:150px; height:148px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Mother</p>
<p style="margin: 0px 0px 0px 0px;">Father</p>
<p style="margin: 0px 0px 0px 0px;">Grandfather</p>
<p style="margin: 0px 0px 0px 0px;">Grandmother</p>
<p style="margin: 0px 0px 0px 0px;">Uncle</p>
<p style="margin: 0px 0px 0px 0px;">Aunt</p>
<p style="margin: 0px 0px 0px 0px;">Brother</p>
<p style="margin: 0px 0px 0px 0px;">Sister</p>
<p style="margin: 0px 0px 0px 0px;">Guardian, Other</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Other Caregiver</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Caregiver Telephone</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Tab:Mother's History</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Mother's ART/PMTCT History</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Name of Mother</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Alive?</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Mother received drugs for PMTCT?</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No/Unknown</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If yes, select drug combination</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multi select list</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">ARV Medications list</p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Has the child received drugs for PMTCT?</p>
</td>
<td style="vertical-align:top; width:150px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td style="vertical-align:top; width:150px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No/Unknown</p>
</td>
<td style="vertical-align:top; width:158px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If yes, select drug combination</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multi select list</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">ARV Medications list</p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Is mother on ART?</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No/Unknown</p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Feeding option up to point of failure or 6 months - which ever is earlier</p>
</td>
<td style="vertical-align:top; width:150px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td colspan="2" style="vertical-align:top; width:150px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Exclusive breast Mixed feeding</p>
<p style="margin: 0px 0px 0px 0px;">Exclusive formula</p>
</td>
<td style="vertical-align:top; width:117px; height:49px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:49px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Tab: HIV Care</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section HIV Care</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date Confirmed HIV Positive</p>
</td>
<td style="vertical-align:top; width:150px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:150px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:158px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date cannot be greater than today's date</p>
</td>
<td style="vertical-align:top; width:149px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:214px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date enrolled in HIV Care</p>
</td>
<td style="vertical-align:top; width:150px; height:214px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:150px; height:214px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="3" style="vertical-align:top; width:158px; height:214px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">NOT auto populated - </p>
<p style="margin: 0px 0px 0px 0px;">Record date patient is newly enrolled into chronic HIV care. This is not the same as the date patient was put on ARVs </p>
<p style="margin: 0px 0px 0px 0px;">If patient is a transfer in, get this date from the referral documents</p>
<p style="margin: 0px 0px 0px 0px;">Auto populate this date from the Technical area enrollment date.</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">WHO Stage at enrollment</p>
</td>
<td style="vertical-align:top; width:150px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td style="vertical-align:top; width:150px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">1,2,3,4 NA</p>
<p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:158px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">At the time of enrollment (NOT at ART start)</p>
</td>
<td style="vertical-align:top; width:149px; height:49px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Tab: Transfer In</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Transfer In</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Transfer In Date</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">From District</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select List</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">District</p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Facility</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select List</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">See facility tab</p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date Started on 1st Line Regimen</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Regimen</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multi select list</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">ARV Medications list</p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Regimen IDs</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Weight (Kgs)</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">One decimal</p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Height (cms)</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">One decimal</p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">BMI (Adults)</p>
</td>
<td style="vertical-align:top; width:150px; height:49px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:150px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Calculated</p>
<p style="margin: 0px 0px 0px 0px;">Weight/(Height^2)</p>
<p style="margin: 0px 0px 0px 0px;">One decimal</p>
</td>
<td style="vertical-align:top; width:117px; height:49px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:49px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">WHO Stage</p>
</td>
<td colspan="2" style="vertical-align:top; width:150px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">1, 2, 3, 4,T1,T2, T3, T4, NA</p>
</td>
<td style="vertical-align:top; width:158px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Tab: Prior ART</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Prior ART</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">(Grid display)</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Prior ART (apart from PMTCT)</p>
</td>
<td style="vertical-align:top; width:150px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No/Unknown</p>
</td>
<td style="vertical-align:top; width:150px; height:99px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="3" style="vertical-align:top; width:158px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If Yes selected then at least one entry must be in the grid; conversely, if No is selected then the grid fields should be disabled.</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Regimen</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Regimen</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Grid view</p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date Last Used</p>
</td>
<td style="vertical-align:top; width:150px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:150px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Grid view</p>
<p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:158px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date cannot be greater than today's date</p>
</td>
<td style="vertical-align:top; width:149px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Tab: Drug Allergies</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Drug Allergies [grid view]</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:150px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Allergen</p>
</td>
<td style="vertical-align:top; width:150px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:49px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:49px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:117px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If filling the grid, this is a required field</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Type of reaction</p>
</td>
<td style="vertical-align:top; width:150px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:150px; height:49px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:49px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:117px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If filling the grid, this is a required field</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date of allergy</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:261px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Relevant Medical Conditions</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multi-line text</p>
</td>
<td style="vertical-align:top; width:150px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:158px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:117px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:149px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
</div>
<p style="text-indent: -18px; margin: 0px 0px 0px 28px;">&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A2_ICON" class="dropdown-toggle-icon" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A2','TOGGLE0186A2_ICON')">Visit</a></td></tr></table></div><div id="TOGGLE0186A2" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none; border-spacing:0px; border-collapse:collapse;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 16pt; font-weight: bold;">Initial and Follow up Visits</span></p>
</td>
<td style="vertical-align:top; width:131px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;">Last updated: June 2014</p>
</td>
<td style="vertical-align:top; width:119px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:131px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:26px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:39px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Labelled</span></p>
</td>
<td style="vertical-align:top; width:131px; height:39px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Display Type</span></p>
</td>
<td style="vertical-align:top; width:253px; height:39px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Options/list/units</span></p>
</td>
<td style="vertical-align:top; width:202px; height:39px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Business Rule</span></p>
</td>
<td style="vertical-align:top; width:119px; height:39px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Required Field</span></p>
</td>
<td style="vertical-align:top; width:99px; height:39px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Data Quality Check</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Tab: Clinical Status</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Visit Details</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Visit Date</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Scheduled</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Checkbox</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Visit Type</p>
</td>
<td style="vertical-align:top; width:131px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select List</p>
</td>
<td style="vertical-align:top; width:253px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Patient Visit</p>
<p style="margin: 0px 0px 0px 0px;">Counselling Only</p>
<p style="margin: 0px 0px 0px 0px;">Refill</p>
</td>
<td style="vertical-align:top; width:202px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Present</p>
</td>
<td style="vertical-align:top; width:131px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select List</p>
</td>
<td style="vertical-align:top; width:253px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">SF - Self</p>
<p style="margin: 0px 0px 0px 0px;">CG - Caregiver</p>
<p style="margin: 0px 0px 0px 0px;">SF/CG - Patient with Caregiver</p>
</td>
<td style="vertical-align:top; width:202px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Do not default</p>
</td>
<td style="vertical-align:top; width:119px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Caregiver Details</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Caregiver Name (Please edit if different.)</p>
</td>
<td style="vertical-align:top; width:131px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:253px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Auto populate from the last visit form (and if first visit - then from the registration form.) The caregiver that comes to the visit may be different than the one in the registration form.</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Caregiver phone number</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Auto populate if available like the name field above</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Hospital Admission</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Admitted to hospital from last visit?</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Number of days hospitalized</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Numeric</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;">If yes to Admitted display this set of fields</p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Where?</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">List of facilities</p>
<p style="margin: 0px 0px 0px 0px;">Must be a custom list</p>
</td>
<td style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000; border-top:none; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Discharge diagnosis</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Can be up to 10 - 150 chars</p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000; border-top:none; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Discharge note</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multiline text</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000; border-top:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Clinical Status</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Duration since Start ART</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Auto populated based on ART Start Date</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Duration since Current Regimen</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Auto populated based on pharmacy forms in the system</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Temp (C )</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Numeric (decimal)</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Add warning popup</p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Weight (kg)</p>
</td>
<td style="vertical-align:top; width:131px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Numeric (decimal)</p>
</td>
<td style="vertical-align:top; width:253px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Allow two decimals</p>
<p style="margin: 0px 0px 0px 0px;">Add warning if not filled as you are entering would be ideal.</p>
</td>
<td style="vertical-align:top; width:99px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Height (cm)</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Numeric (decimal)</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Add warning popup</p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">BMI</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Auto populated</p>
<p style="margin: 0px 0px 0px 0px;">Weight/(Height^2)</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Respiratory Rate</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Integer</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Pulse</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Integer</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">BP- Systolic</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Integer</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">BP - Diastolic</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Integer</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Head circumference (cm)</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Numeric - 1 decimal</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">MUAC (cm)</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Numeric - 1 decimal</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Developmental Status</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:76px; padding:0px; border:solid 1px #000000; border-top:none;"><p style="margin: 0px 0px 0px 0px;">Developmental Screening</p>
</td>
<td style="vertical-align:top; width:131px; height:76px; padding:0px; border:solid 1px #000000; border-top:none;"><p style="margin: 0px 0px 0px 0px;">Select List</p>
</td>
<td style="vertical-align:top; width:253px; height:76px; padding:0px; border:solid 1px #000000; border-top:none;"><p style="margin: 0px 0px 0px 0px;">Normal/Delayed/Not Evaluated</p>
<p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:76px; padding:0px; border:solid 1px #000000; border-top:none;"><p style="margin: 0px 0px 0px 0px;">Display this question fi patient is &lt;6 years old.</p>
<p style="margin: 0px 0px 0px 0px;">See page 13 of the Road to health book</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Tanner Stage</p>
</td>
<td style="vertical-align:top; width:131px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select List</p>
</td>
<td style="vertical-align:top; width:253px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">1, 2, 3, 4, 5</p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Display tanner stage if patient is &gt;= 10 years old</p>
<p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Sexually Active</p>
</td>
<td style="vertical-align:top; width:131px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:253px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">if tanner scale = 3 + then display sexually active and family planning section</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Pregnant?</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">For females only and yes to sexually active</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Protected sex?</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:132px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">What other Family Planning Method are you using?</p>
</td>
<td style="vertical-align:top; width:131px; height:132px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multiselect list</p>
</td>
<td style="vertical-align:top; width:253px; height:132px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Male condoms</p>
<p style="margin: 0px 0px 0px 0px;">Female condoms</p>
<p style="margin: 0px 0px 0px 0px;">Birth control</p>
<p style="margin: 0px 0px 0px 0px;">IUD or Implant</p>
<p style="margin: 0px 0px 0px 0px;">Injectibles</p>
<p style="margin: 0px 0px 0px 0px;">Other</p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:132px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If sexually active, then display family planning method</p>
<p style="margin: 0px 0px 0px 0px;">Needs to be a multi select list</p>
<p style="margin: 0px 0px 0px 0px;">If condoms are used in yes/no question - then prepopulate condoms as checked in multi select list. Don't display this question if pregnant = yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Other FP methods</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Texbox</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Tab: Clinical History/Findings</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Clinical &nbsp;Findings</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:280px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Physical Findings</p>
</td>
<td style="vertical-align:top; width:131px; height:280px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multi select &nbsp;list</p>
</td>
<td colspan="4" style="vertical-align:top; width:253px; height:280px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Anaemia</p>
<p style="margin: 0px 0px 0px 0px;">Clubbing</p>
<p style="margin: 0px 0px 0px 0px;">Thrush</p>
<p style="margin: 0px 0px 0px 0px;">Dental caries</p>
<p style="margin: 0px 0px 0px 0px;">Seborrhoeic Dermatitisis</p>
<p style="margin: 0px 0px 0px 0px;">Papular Rash</p>
<p style="margin: 0px 0px 0px 0px;">Suppurative Otitis</p>
<p style="margin: 0px 0px 0px 0px;">Parotomegaly</p>
<p style="margin: 0px 0px 0px 0px;">Indrawing</p>
<p style="margin: 0px 0px 0px 0px;">Generalized Lymphadenopathy</p>
<p style="margin: 0px 0px 0px 0px;">RUQ tenderness</p>
<p style="margin: 0px 0px 0px 0px;">Jaundice</p>
<p style="margin: 0px 0px 0px 0px;">Hepatomegaly</p>
<p style="margin: 0px 0px 0px 0px;">Splenomegaly</p>
<p style="margin: 0px 0px 0px 0px;">Absent Ankle Jerk</p>
<p style="margin: 0px 0px 0px 0px;">Other (specify)</p>
<p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Other Findings</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Text box</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Place this field in the modal</p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Clinical Stage</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select List</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">1, 2, 3, 4, NA</p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Provide a link to the pdf file instructions</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;">Clinical Notes</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;">Multiline text</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;">One or more adverse events?</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;">If yes, display adverse event fields</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000; border-bottom:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:148px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Adverse Event Name</p>
</td>
<td style="vertical-align:top; width:131px; height:148px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">MultiSelect List - with Severity select list for each that can be classified</p>
</td>
<td style="vertical-align:top; width:253px; height:148px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">See Gerry's list; display a pop up grid with event names and severities if applicable</p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:148px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">See categorized list from gerry &nbsp;some do not have a severity associated and either the select list should not be displayed or it should be inactive. &nbsp; Default to none. Provide a link to a pdf of the adverse event listing and classification</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Adverse Event Other</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Textbox</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:115px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Adverse Event Severity Grade</p>
</td>
<td style="vertical-align:top; width:131px; height:115px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td style="vertical-align:top; width:253px; height:115px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">1,2,3,4</p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:115px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">This data will be in the pop up grid</p>
<p style="margin: 0px 0px 0px 0px;">Remind to put the lab into the lab section</p>
<p style="margin: 0px 0px 0px 0px;">OR allow to enter right here and drop data into the lab table.</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Comment on Adverse Event</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multiline textbox</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Only display if an adverse event</p>
</td>
<td style="vertical-align:top; width:119px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Sub-Section: TB Contact</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Is there any new TB contact?</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If Yes</p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Do you know the sensitivity of the TB?</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If Yes</p>
</td>
<td style="vertical-align:top; width:119px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Please indicate</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Use TB select list with sensitivitify and resistance</p>
</td>
<td style="vertical-align:top; width:119px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Do you know what treatment the contact is getting?</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Use same list</p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list should be ordered as per Gerry</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Please select treatment</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Use TB select list</p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If yes</p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Do you know if this contact is getting daily injections?</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If No to sensitivity question</p>
</td>
<td style="vertical-align:top; width:119px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:132px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Which of the following forms of treatment do you think the contact is receiving?</p>
</td>
<td style="vertical-align:top; width:131px; height:132px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select List</p>
</td>
<td style="vertical-align:top; width:253px; height:132px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Drug sensitive TB</p>
<p style="margin: 0px 0px 0px 0px;">INH monoresistant</p>
<p style="margin: 0px 0px 0px 0px;">Rif monoresistant</p>
<p style="margin: 0px 0px 0px 0px;">MDR</p>
<p style="margin: 0px 0px 0px 0px;">XDR</p>
<p style="margin: 0px 0px 0px 0px;">INH TB Prophlyaxis</p>
<p style="margin: 0px 0px 0px 0px;">Other TB Prophlyaxis</p>
<p style="margin: 0px 0px 0px 0px;">Unknown</p>
</td>
<td style="vertical-align:top; width:202px; height:132px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If No to sensitivity question</p>
<p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:132px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:132px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Other TB Prophylaxis</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Texbox</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If other TB Prophylaxis display other</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Sub-Section: TB Patient Screening</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">TB Status</p>
</td>
<td style="vertical-align:top; width:131px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select List</p>
</td>
<td style="vertical-align:top; width:253px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">No Signs</p>
<p style="margin: 0px 0px 0px 0px;">TB Suspected</p>
<p style="margin: 0px 0px 0px 0px;">TB Rx</p>
<p style="margin: 0px 0px 0px 0px;">Completing TB treatment now</p>
<p style="margin: 0px 0px 0px 0px;">TB Prophylaxis</p>
<p style="margin: 0px 0px 0px 0px;">Screening Not Done</p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If on TB Rx then display start date</p>
<p style="margin: 0px 0px 0px 0px;">if start date is not null, display the question &quot;Still on treatment?&quot;</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">TB Rx start date</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If TB Rx</p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Still on treatment?</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If TB Rx</p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">TB Rx end date</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If Completing TB Treatment selected</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If TB Rx, how was the diagnosis made?</p>
</td>
<td style="vertical-align:top; width:131px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multi select list</p>
</td>
<td style="vertical-align:top; width:253px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Exposure</p>
<p style="margin: 0px 0px 0px 0px;">Clinical findings</p>
<p style="margin: 0px 0px 0px 0px;">Chest X-ray changes</p>
<p style="margin: 0px 0px 0px 0px;">AFB on sputum</p>
<p style="margin: 0px 0px 0px 0px;">TB culture on sputum</p>
<p style="margin: 0px 0px 0px 0px;">Gene Xpert</p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If TB Rx</p>
<p style="margin: 0px 0px 0px 0px;">Display first time TB selected</p>
</td>
<td style="vertical-align:top; width:99px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Do you have new sensitivity informaiton?</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If Yes to TB Rx or Still on Treatment</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Please indicate</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Use TB select list with sensitivitify and resistance</p>
</td>
<td style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If Yes</p>
</td>
<td style="vertical-align:top; width:119px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:115px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Patient's TB Treatment</p>
</td>
<td style="vertical-align:top; width:131px; height:115px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select List</p>
</td>
<td style="vertical-align:top; width:253px; height:115px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Drug sensitive TB</p>
<p style="margin: 0px 0px 0px 0px;">INH monoresistant</p>
<p style="margin: 0px 0px 0px 0px;">Rif monoresistant</p>
<p style="margin: 0px 0px 0px 0px;">MDR</p>
<p style="margin: 0px 0px 0px 0px;">XDR</p>
<p style="margin: 0px 0px 0px 0px;">INH TB Prophlyaxis</p>
<p style="margin: 0px 0px 0px 0px;">Other TB Prophlyaxis</p>
</td>
<td style="vertical-align:top; width:202px; height:115px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If yes to TB Rx (not to sensitivity question above)</p>
<p style="margin: 0px 0px 0px 0px;">Auto populate from the last visit it was captured</p>
<p style="margin: 0px 0px 0px 0px;">Display prior TB history from first TB Rx start and dates</p>
</td>
<td style="vertical-align:top; width:119px; height:115px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
<td style="vertical-align:top; width:99px; height:115px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Other TB Prophylaxis</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Texbox</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If other TB Prophylaxis display other</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Nutrition</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Feeding practice</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">[Exclusive Breast Feeding, Replacement Feeding, Mixed Feeding]</p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If patient is &lt;2 years old display this field</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:181px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Nutritional Problems</p>
</td>
<td style="vertical-align:top; width:131px; height:181px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td style="vertical-align:top; width:253px; height:181px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Normal</p>
<p style="margin: 0px 0px 0px 0px;">Moderate Acute Malnutrition</p>
<p style="margin: 0px 0px 0px 0px;">Overweight for age/height</p>
<p style="margin: 0px 0px 0px 0px;">Severe overweight for age/height</p>
<p style="margin: 0px 0px 0px 0px;">Poor Weight Gain/Under weight for age/height</p>
<p style="margin: 0px 0px 0px 0px;">Severe Acute Malnutrition uncomplicated</p>
<p style="margin: 0px 0px 0px 0px;">Severe Acute Malnutrition complicated</p>
<p style="margin: 0px 0px 0px 0px;">Severe Acute Malnutrition complicated with Oedoma</p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:181px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Display two links 1) pdf file with weight for age and 2) pdf file with weight for height</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:148px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Nutritional Support</p>
</td>
<td style="vertical-align:top; width:131px; height:148px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td style="vertical-align:top; width:253px; height:148px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Therapeutic Feeding </p>
<p style="margin: 0px 0px 0px 0px;">Infant Feeding Counselling</p>
<p style="margin: 0px 0px 0px 0px;">Nutrition Counselling <span style="text-decoration: line-through;">only</span></p>
<p style="margin: 0px 0px 0px 0px;">Food Support</p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:148px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list filtering requested; possibly display as check boxes instead.</p>
<p style="margin: 0px 0px 0px 0px;">If &lt; 2 yrs display only TF</p>
<p style="margin: 0px 0px 0px 0px;">If female and &gt;=9 years display IFC AND FS AND &quot;Nutrition Counselling&quot;</p>
<p style="margin: 0px 0px 0px 0px;">All others display FS AND &quot;Nutrition Counselling&quot;</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Tab: Pharmacy &amp; Lab</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Adherence</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Was the prescription of the previous visit dispensed as prescribed?</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If no, please describe the problem</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multiline Textbox</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">CTX Adherence</p>
</td>
<td style="vertical-align:top; width:131px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select List</p>
</td>
<td style="vertical-align:top; width:253px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Good</p>
<p style="margin: 0px 0px 0px 0px;">Fair</p>
<p style="margin: 0px 0px 0px 0px;">Poor</p>
</td>
<td style="vertical-align:top; width:202px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">ARV Adherence</p>
</td>
<td style="vertical-align:top; width:131px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select List</p>
</td>
<td style="vertical-align:top; width:253px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Good</p>
<p style="margin: 0px 0px 0px 0px;">Fair</p>
<p style="margin: 0px 0px 0px 0px;">Poor</p>
</td>
<td style="vertical-align:top; width:202px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:231px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Why poor/fair ARV Adherence</p>
</td>
<td style="vertical-align:top; width:131px; height:231px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multi select &nbsp;list</p>
</td>
<td style="vertical-align:top; width:253px; height:231px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Toxicity/Side effects</p>
<p style="margin: 0px 0px 0px 0px;">Share with others</p>
<p style="margin: 0px 0px 0px 0px;">Forgot</p>
<p style="margin: 0px 0px 0px 0px;">Felt Better</p>
<p style="margin: 0px 0px 0px 0px;">Too ill</p>
<p style="margin: 0px 0px 0px 0px;">Stigma, disclosure or privacy issue</p>
<p style="margin: 0px 0px 0px 0px;">Drug stock out</p>
<p style="margin: 0px 0px 0px 0px;">Patient lost/run out of pills</p>
<p style="margin: 0px 0px 0px 0px;">Delivery/travel problems</p>
<p style="margin: 0px 0px 0px 0px;">Inability to pay</p>
<p style="margin: 0px 0px 0px 0px;">Alcohol</p>
<p style="margin: 0px 0px 0px 0px;">Depression</p>
<p style="margin: 0px 0px 0px 0px;">Pill Burden</p>
<p style="margin: 0px 0px 0px 0px;">Other Specify</p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:231px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If Fair or Poor selected, display this Why poor/fair ARV adherence list.</p>
<p style="margin: 0px 0px 0px 0px;">Accesses a custom list</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Other poor/fair ARV reason</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">TextSingleLine</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Regimen Plan</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">*Substitutions/Interruptions</p>
</td>
<td style="vertical-align:top; width:131px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select List</p>
</td>
<td style="vertical-align:top; width:253px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Treatment not indicated now</p>
<p style="margin: 0px 0px 0px 0px;">Continue current treatment</p>
<p style="margin: 0px 0px 0px 0px;">Restart treatment</p>
<p style="margin: 0px 0px 0px 0px;">Start new treatment (naïve patient)</p>
<p style="margin: 0px 0px 0px 0px;">Change regimen</p>
<p style="margin: 0px 0px 0px 0px;">Stop treatment</p>
</td>
<td style="vertical-align:top; width:202px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Required field</p>
</td>
<td style="vertical-align:top; width:119px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes</p>
</td>
<td style="vertical-align:top; width:99px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:165px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Change Regimen Reason</p>
</td>
<td style="vertical-align:top; width:131px; height:165px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multi select &nbsp;list</p>
</td>
<td style="vertical-align:top; width:253px; height:165px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Toxicity/Side effects/Adverse Event</p>
<p style="margin: 0px 0px 0px 0px;">Pregnancy</p>
<p style="margin: 0px 0px 0px 0px;">Risk of pregnancy</p>
<p style="margin: 0px 0px 0px 0px;">Due to new TB</p>
<p style="margin: 0px 0px 0px 0px;">New drug available</p>
<p style="margin: 0px 0px 0px 0px;">Drug out of stock</p>
<p style="margin: 0px 0px 0px 0px;">Clinical treatment failure</p>
<p style="margin: 0px 0px 0px 0px;">Immunologic failure</p>
<p style="margin: 0px 0px 0px 0px;">Virologic failure</p>
<p style="margin: 0px 0px 0px 0px;">Other reasons (specify)</p>
</td>
<td style="vertical-align:top; width:202px; height:165px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If Change Regimen, display the Change Regimen reason list -if Adverse Event display multi select list of events</p>
<p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:119px; height:165px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Cannot save if at least one adverse event not selected above</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Change reason other</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">TextSingleLine</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Display if Other change reason selected</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:165px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Stop Regimen Reason</p>
</td>
<td style="vertical-align:top; width:131px; height:165px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multi select &nbsp;list</p>
</td>
<td style="vertical-align:top; width:253px; height:165px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Toxicity/Side effect/Adverse Event</p>
<p style="margin: 0px 0px 0px 0px;">Pregnancy</p>
<p style="margin: 0px 0px 0px 0px;">Treatment failure</p>
<p style="margin: 0px 0px 0px 0px;">Poor adherence</p>
<p style="margin: 0px 0px 0px 0px;">Illness, hospitalization</p>
<p style="margin: 0px 0px 0px 0px;">Drugs out of stock</p>
<p style="margin: 0px 0px 0px 0px;">Patient lacks finances</p>
<p style="margin: 0px 0px 0px 0px;">Other patient decision</p>
<p style="margin: 0px 0px 0px 0px;">Planned Rx interruption</p>
<p style="margin: 0px 0px 0px 0px;">Other (specify)</p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:165px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If Stop Regimen, display the Stop Regimen reason list -if Adverse Event display multi select list of events</p>
<p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Stop reason other</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">TextSingleLine</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Display if Other stopped reason selected</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:66px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">ART End Date</p>
</td>
<td style="vertical-align:top; width:131px; height:66px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:253px; height:66px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:66px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date must be less than or equal to today's date</p>
<p style="margin: 0px 0px 0px 0px;">Date must be greater than registration date</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Prescribe Drugs BUTTON</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Laboratory Investigations</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:top; width:242px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Laboratory Investigations Lab Order BUTTON</p>
</td>
<td colspan="3" style="vertical-align:top; width:253px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Add instruction text:</p>
<p style="margin: 0px 0px 0px 0px;">Use lab order test button to order labs and document results.</p>
</td>
<td style="vertical-align:top; width:99px; height:49px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Tab: Visit Finalisation</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ffcc99; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Disclosure</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Disclosed to child?</p>
</td>
<td style="vertical-align:top; width:131px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:253px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="2" style="vertical-align:top; width:202px; height:33px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Auto populate if previously asked and answered</p>
</td>
<td style="vertical-align:top; width:99px; height:33px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Level of disclosure</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Level 1, Level 2, Level 3, Level 4</p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If Yes selected, display field</p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Referral and Consultations</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:214px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Referred To</p>
</td>
<td style="vertical-align:top; width:131px; height:214px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Multi select list</p>
</td>
<td style="vertical-align:top; width:253px; height:214px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">PMTCT</p>
<p style="margin: 0px 0px 0px 0px;">HBC</p>
<p style="margin: 0px 0px 0px 0px;">PLHA Support Group/Club</p>
<p style="margin: 0px 0px 0px 0px;">Orphan and vulnerable children group</p>
<p style="margin: 0px 0px 0px 0px;">Medical specialty</p>
<p style="margin: 0px 0px 0px 0px;">Nutritional support</p>
<p style="margin: 0px 0px 0px 0px;">Legal</p>
<p style="margin: 0px 0px 0px 0px;">Social worker</p>
<p style="margin: 0px 0px 0px 0px;">Occupational therapist</p>
<p style="margin: 0px 0px 0px 0px;">Physiotherapist</p>
<p style="margin: 0px 0px 0px 0px;">Psychologist</p>
<p style="margin: 0px 0px 0px 0px;">Counsellor</p>
<p style="margin: 0px 0px 0px 0px;">Other (specify)</p>
</td>
<td style="vertical-align:top; width:202px; height:214px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Make a custom list</p>
</td>
<td style="vertical-align:top; width:119px; height:214px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:214px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Referred To Other</p>
</td>
<td style="vertical-align:top; width:131px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Text</p>
</td>
<td style="vertical-align:top; width:253px; height:49px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:49px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If Other (specify) is selected, then display the text box within the multi select control</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-weight: bold;">Section: Next Appointment</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Transfer out?</p>
</td>
<td style="vertical-align:top; width:131px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Yes/No</p>
</td>
<td style="vertical-align:top; width:253px; height:99px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If yes, then display CARE ENDED button. If button clicked open care ended form.</p>
<p style="margin: 0px 0px 0px 0px;">In CE form, pre-populate the Transfer Out exit reason and display the facility list.</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Next appointment Date</p>
</td>
<td style="vertical-align:top; width:131px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td style="vertical-align:top; width:253px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">2 weeks, 4 weeks, 8 weeks, 12 weeks</p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:99px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select the next appointment week; date selected then displays the date picker with the calculated date selected; The user then confirms the date.</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:82px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:131px; height:82px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Date</p>
</td>
<td style="vertical-align:top; width:253px; height:82px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="3" style="vertical-align:top; width:202px; height:82px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Paperless - Date must be strictly greater than today's date</p>
<p style="margin: 0px 0px 0px 0px;">Paperbased - then can be any date</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:242px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Signature</p>
</td>
<td style="vertical-align:top; width:131px; height:16px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Select list</p>
</td>
<td style="vertical-align:top; width:253px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:202px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:119px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:99px; height:16px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
</div>
<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A3_ICON" class="dropdown-toggle-icon" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A3','TOGGLE0186A3_ICON')">Immunisation</a></td></tr></table></div><div id="TOGGLE0186A3" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none; border-spacing:0px; border-collapse:collapse;">
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:top; width:202px; height:30px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 18pt; font-family: Calibri; font-weight: bold;">Immunisation Tracking</span></p>
</td>
<td style="vertical-align:top; width:164px; height:30px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="3" style="vertical-align:top; width:190px; height:30px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Based on Road to Health booklet</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri; font-weight: bold;">Grid view</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:97px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:134px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri; font-weight: bold;">Road to health card available</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:97px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:134px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:97px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:134px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:40px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Labelled</span></p>
</td>
<td style="vertical-align:top; width:168px; height:40px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Display Type</span></p>
</td>
<td style="vertical-align:top; width:164px; height:40px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Options/list/units</span></p>
</td>
<td style="vertical-align:top; width:190px; height:40px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Business Rule</span></p>
</td>
<td style="vertical-align:top; width:97px; height:40px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Required Field</span></p>
</td>
<td style="vertical-align:top; width:134px; height:40px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Data Quality Check</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:368px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Immunisation</span></p>
</td>
<td style="vertical-align:top; width:168px; height:368px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Checkbox</span></p>
</td>
<td style="vertical-align:top; width:164px; height:368px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">BCG</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">OPV0</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">OPV1</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">RV1</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">DTaP-IPV-Hib1</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Hep B1</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">PCV1</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">DTaP-IPV-Hib2</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Hep B2</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">DTaP-IPV-Hib3</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Hep B3</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">PCV2</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">RV2</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Measles1</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">PCV3</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">DTaP-IPV-Hib4</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Measles2</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Td - 6 yrs</span></p>
<p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Td - 12 yrs</span></p>
</td>
<td style="vertical-align:top; width:190px; height:368px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">At least one immunisation needs to be checked to save the form</span></p>
</td>
<td style="vertical-align:top; width:97px; height:368px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes</span></p>
</td>
<td style="vertical-align:top; width:134px; height:368px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Immunisation Date</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:97px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:134px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Catch up given today</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Checkbox</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:97px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:134px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
<p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
</table>
</div>
<p>&nbsp;</p>
<p>&nbsp;</p>
<p>&nbsp;</p>
<p>&nbsp;</p>
<p><span style="font-weight: bold;">Form Set up</span></p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none; border-spacing:0px; border-collapse:collapse;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri; font-weight: bold;">Age group</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri; font-weight: bold;">Vaccine</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri; font-weight: bold;">Date given</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri; font-weight: bold;">Catch up given today</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; background-color:#ccccff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Birth</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">BCG</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">OPV0</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">6 weeks</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">OPV1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">RV1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">DTaP-IPV- Hib1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Hep B1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">PCV1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">10 weeks</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">DTaP-IPV- Hib2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Hep B2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">14 weeks</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">DTaP-IPV- Hib3</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Hep B3</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">PCV2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">RV2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">9 months</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Measles1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">PCV3</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">DTaP-IPV- Hib4</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Measles2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">6 years</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Td - 6 yrs</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">12 years</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Td - 12 yrs</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Yes/No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; background-color:#ffff00; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Add Immunusation</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
</div>
<p>&nbsp;</p>
<p>&nbsp;</p>
<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A4_ICON" class="dropdown-toggle-icon" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A4','TOGGLE0186A4_ICON')">Care Ended</a></td></tr></table></div><div id="TOGGLE0186A4" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none; border-spacing:0px; border-collapse:collapse;">
<tr style="text-align:left;vertical-align:top;">
<td colspan="2" style="vertical-align:top; width:202px; height:30px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 18pt; font-family: Calibri; font-weight: bold;">Care Ended</span></p>
</td>
<td style="vertical-align:top; width:164px; height:30px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td colspan="3" style="vertical-align:top; width:190px; height:30px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:97px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:134px; height:19px; padding:0px; border:solid 1px #000000; border-top:none; border-right:none; border-bottom:none; border-left:none;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:40px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Labelled</span></p>
</td>
<td style="vertical-align:top; width:168px; height:40px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Display Type</span></p>
</td>
<td style="vertical-align:top; width:164px; height:40px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Options/list/units</span></p>
</td>
<td style="vertical-align:top; width:190px; height:40px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Business Rule</span></p>
</td>
<td style="vertical-align:top; width:97px; height:40px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Required Field</span></p>
</td>
<td style="vertical-align:top; width:134px; height:40px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold;">Data Quality Check</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:21px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date of Missed Appointment</span></p>
</td>
<td style="vertical-align:top; width:168px; height:21px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:164px; height:21px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:21px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:97px; height:21px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:134px; height:21px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date of Last Actual Contact</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Auto populate from the last clinical form date</p>
</td>
<td style="vertical-align:top; width:97px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:134px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Exit Reason</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Select list</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">[Lost to Follow up, Transfer to another facility, Confirmed HIV Negative, Death]</p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:97px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Required</p>
</td>
<td style="vertical-align:top; width:134px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Lost to Follow up Reason</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Textbox</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If LTFU reason is Yes then display this text box</p>
</td>
<td style="vertical-align:top; width:97px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:134px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Transfer to another facility</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Select list</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Facility list</p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">See facility tab</p>
</td>
<td style="vertical-align:top; width:97px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:134px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Transfer Date</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Cannot transfer before todays date and cannot transfer before the enrollment date</p>
</td>
<td style="vertical-align:top; width:97px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:134px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Death Date</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If exit reason is death, display death date</p>
</td>
<td style="vertical-align:top; width:97px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:134px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:17px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Suspected Death Reason</span></p>
</td>
<td style="vertical-align:top; width:168px; height:17px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Select list</span></p>
</td>
<td style="vertical-align:top; width:164px; height:17px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">HIV-Related</p>
<p style="margin: 0px 0px 0px 0px;">Not HIV-Related</p>
</td>
<td style="vertical-align:top; width:190px; height:17px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">If exit reason is death, display death reason</p>
</td>
<td style="vertical-align:top; width:97px; height:17px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:134px; height:17px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Comments</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">MultiText</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:97px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:134px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:202px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Care Ended Date</span></p>
</td>
<td style="vertical-align:top; width:168px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-family: Calibri;">Date</span></p>
</td>
<td style="vertical-align:top; width:164px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:190px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:97px; height:19px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;">Required</p>
</td>
<td style="vertical-align:top; width:134px; height:19px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
</table>
</div>
<p>&nbsp;</p>
</td>
</tr>
</table>
</div>
<p>&nbsp;</p>
<p>&nbsp;</p>
<p>&nbsp;</p>
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